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Dall T.M.,Lewin Group | Zhang Y.,Lewin Group | Chen Y.J.,Lewin Group | Quick W.W.,Endocrinology and Metabolic Disease | And 2 more authors.
Health Affairs | Year: 2010

New research provides revised comprehensive estimates that suggest that the U.S. national economic burden of pre-diabetes and diabetes reached $218 billion in 2007. This estimate includes $153 billion in higher medical costs and $65 billion in reduced productivity. The average annual cost per case is $2,864 for undiagnosed diabetes, $9,975 for diagnosed diabetes ($9,677 for type 2 and $14,856 for type 1), and $443 for pre-diabetes (medical costs only). For each American, regardless of diabetes status, this burden represents a cost of approximately $700 annually. These results underscore the urgency of better understanding how prevention and treatment strategies may or may not help reduce costs. © 2010 Project HOPE-The People-to-People Health Foundation, Inc.


Robison J.,University of Connecticut Health Center | Shugrue N.,University of Connecticut Health Center | Fortinsky R.H.,University of Connecticut Health Center | Gruman C.,Lewin Group
Gerontologist | Year: 2014

Purpose of the Study: Little is known about adults' future planning for long-term supports and services (LTSS), and no studies have examined how LTSS planning compares between Baby Boomers and their parents' generation. The primary aim of this study is to examine the potential influences of birth cohort and gender on LTSS planning. Drawing on Andersen's Behavioral Model of Health Services Use, birth cohort and gender are viewed as predisposing characteristics, and several additional predisposing, enabling, and need characteristics are included as independent variables. Design and Methods: Cross-sectional design; data obtained from a statewide survey of 2,522 randomly selected Baby Boomers (born between 1946 and 1964) and older adults (born before 1946). Results: Two thirds of respondents expected to need LTSS, but few reported saving for such services. Controlling for other independent variables, compared with older adults, Baby Boomers were significantly more likely to plan to move to an apartment, live in a retirement community or assisted living, and live with an adult child. Conversely, women were more likely than men to report planning to use specific LTSS such as homecare, but specific LTSS plans did not vary by birth cohort. Implications: Policymakers and providers should prepare for a shift in community planning to accommodate the changing plans and expectations of Baby Boomers, large numbers of whom plan to age in existing homes and retirement communities, or live with adult children, with increasing demand for informal family support. The LTSS industry should also adapt to meet the need for formal services, which will likely continue to grow. © 2013 The Author.


Jones I.W.,University of Manitoba | Hooker R.S.,Lewin Group
Canadian Family Physician | Year: 2011

Objective: To analyze the health policies related to physician assistants (PAs) and to understand the factors influencing this medical work force movement. Quality of evidence: This work combines a review of the literature and qualitative information, and it serves as a historical bookmark. The approach was selected when attempts to obtain reports or literature using customary electronic bibliography (PubMed, CINAHL, Google Scholar, EBSCO, and MEDLINE) searches in English and French, from 1970 through 2010, identified only 14 documents (including gray literature) of relevance. Reports, provincial documents, and information from developers of the PA movement supplemented the literature base. Main message: The historical development of the role of PAs in Canada spans 2 decades. There are now more than 250 PAs, most working in family medicine and emergency medicine. Enabling legislation for PAs has been formalized in Manitoba, and 3 provinces have recognized PAs in various policy statements or initiatives. Three universities and 1 military training centre have enrolled more than 120 students in PA programs. Retired PAs of the Canadian Forces, returning ex-patriot Canadians who had trained as PAs in PA programs in the United States, and American immigrants are working as PAs in Canada. Demonstration projects are under way to better understand the usefulness of PAs in various medical settings. Conclusion: For a public health policy enactment of this size and effect, the literature on PAs in Canada is sparse and limited. In spite of this, PA employment is expanding, family medicine practices are using PAs, and there is enabling legislation planned. The result will likely be increased use of PAs. Documentation about PAs, review of their use, and outcomes research are needed to evaluate this new type of clinician in Canadian society.


Jain A.,Lewin Group | Marshall J.,Lewin Group | Buikema A.,Optum Inc | Bancroft T.,Optum Inc | And 2 more authors.
JAMA - Journal of the American Medical Association | Year: 2015

IMPORTANCE: Despite research showing no link between the measles-mumps-rubella (MMR) vaccine and autism spectrum disorders (ASD), beliefs that the vaccine causes autism persist, leading to lower vaccination levels. Parents who already have a child with ASD may be especially wary of vaccinations. OBJECTIVE: To report ASD occurrence by MMR vaccine status in a large sample of US children who have older siblings with and without ASD. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study using an administrative claims database associated with a large commercial health plan. Participants included children continuously enrolled in the health plan from birth to at least 5 years of age during 2001-2012 who also had an older sibling continuously enrolled for at least 6 months between 1997 and 2012. EXPOSURES: MMR vaccine receipt (0, 1, 2 doses) between birth and 5 years of age. MAIN OUTCOMES AND MEASURES: ASD status defined as 2 claims with a diagnosis code in any position for autistic disorder or other specified pervasive developmental disorder (PDD) including Asperger syndrome, or unspecified PDD (International Classification of Diseases, Ninth Revision, Clinical Modification 299.0x, 299.8x, 299.9x). RESULTS: Of 95 727 children with older siblings, 994 (1.04%) were diagnosed with ASD and 1929 (2.01%) had an older sibling with ASD. Of those with older siblings with ASD, 134 (6.9%) had ASD, vs 860 (0.9%) children with unaffected siblings (P < .001). MMR vaccination rates (≥1 dose) were 84% (n = 78 564) at age 2 years and 92% (n = 86 063) at age 5 years for children with unaffected older siblings, vs 73% (n = 1409) at age 2 years and 86% (n = 1660) at age 5 years for children with affected siblings. MMR vaccine receipt was not associated with an increased risk of ASD at any age. For children with older siblings with ASD, at age 2, the adjusted relative risk (RR) of ASD for 1 dose of MMR vaccine vs no vaccine was 0.76 (95% CI, 0.49-1.18; P = .22), and at age 5, the RR of ASD for 2 doses compared with no vaccine was 0.56 (95% CI, 0.31-1.01; P = .052). For children whose older siblings did not have ASD, at age 2, the adjusted RR of ASD for 1 dose was 0.91 (95% CI, 0.67-1.20; P = .50) and at age 5, the RR of ASD for 2 doses was 1.12 (95% CI, 0.78-1.59; P = .55). CONCLUSIONS AND RELEVANCE: In this large sample of privately insured children with older siblings, receipt of the MMR vaccine was not associated with increased risk of ASD, regardless of whether older siblings had ASD. These findings indicate no harmful association between MMR vaccine receipt and ASD even among children already at higher risk for ASD. Copyright 2015 American Medical Association. All rights reserved.


Dall T.M.,IHS Life science | Yang W.,Lewin Group | Halder P.,Lewin Group | Pang B.,Lewin Group | And 5 more authors.
Diabetes Care | Year: 2014

OBJECTIVE: To update estimates of the economic burden of undiagnosed diabetes, prediabetes, and gestational diabetesmellitus in 2012 in the U.S. and to present state-level estimates. Combined with published estimates for diagnosed diabetes, these statistics provide a detailed picture of the economic costs associated with elevated glucose levels. RESEARCH DESIGN AND METHODS: This study estimated health care use and medical expenditures in excess of expected levels occurring in the absence of diabetes or prediabetes. Data sources that were analyzed include Optum medical claims for ∼4.9 million commercially insured patients who were continuously enrolled from 2010 to 2012, Medicare Standard Analytical Files containing medical claims for ∼2.6 million Medicare patients in 2011, and the 2010 Nationwide Inpatient Sample containing ∼7.8 million hospital discharge records. The indirect economic burden includes reduced labor force participation, missed workdays, and reduced productivity. State-level estimates reflect geographic variation in prevalence, risk factors, and prices. RESULTS: The economic burden associated with diagnosed diabetes (all ages) and undiagnosed diabetes, gestational diabetes, and prediabetes (adults) exceeded $322 billion in 2012, consisting of $244 billion in excess medical costs and $78 billion in reduced productivity. Combined, this amounts to an economic burden exceeding $1,000 for each American in 2012. This national estimate is 48% higher than the $218 billion estimate for 2007. The burden per case averaged $10,970 for diagnosed diabetes, $5,800 for gestational diabetes, $4,030 for undiagnosed diabetes, and $510 for prediabetes. CONCLUSIONS: These statistics underscore the importance of finding ways to reduce the burden of prediabetes and diabetes through prevention and treatment. © 2014 by the American Diabetes Association.


Sargen M.,University of Pennsylvania | Hooker R.S.,Lewin Group | Cooper R.A.,University of Pennsylvania
Journal of the American College of Surgeons | Year: 2011

Background: Based on the goals of health care reform, growth in the demand for health care will continue to increase the demand for physicians and, as physician shortages widen, advanced practice nurses (APNs) and physician assistants (PAs) will play larger roles. Together with physicians they constitute a workforce of "advanced clinicians." The objective of this study was to assess the capacity of this combined workforce to meet the future demand for clinical services. Study Design: Projections were constructed to the year 2025 for the supply of physicians, APNs, and PAs, and these were compared with projections of the demand for advanced clinical services, based on federal estimates of future spending and historic relationships between spending and the health care labor force. Results: If training programs for APNs and PAs grow as currently projected but physician residency programs are not further expanded, the aggregate per capita supply of advanced clinicians will remain close to its current level, which will be 20% less than the demand in 2025. Increasing the numbers of entry-level (PGY1) residents by 500 annually will narrow the gap, but it will remain >15%. Conclusions: The nation faces a substantial shortfall in its combined supply of physicians, APNs, and PAs, even under aggressive training scenarios, and deeper shortages if these scenarios are not achieved. Efforts must be made to expand the output of clinicians in all 3 disciplines, while also strengthening the infrastructure of clinical practice and facilitating the delegation of tasks to a broadened spectrum of caregivers in new models of care. © 2011 by the American College of Surgeons.


Dall T.M.,Lewin Group
Health affairs (Project Hope) | Year: 2010

New research provides revised comprehensive estimates that suggest that the U.S. national economic burden of pre-diabetes and diabetes reached $218 billion in 2007. This estimate includes $153 billion in higher medical costs and $65 billion in reduced productivity. The average annual cost per case is $2,864 for undiagnosed diabetes, $9,975 for diagnosed diabetes ($9,677 for type 2 and $14,856 for type 1), and $443 for pre-diabetes (medical costs only). For each American, regardless of diabetes status, this burden represents a cost of approximately $700 annually. These results underscore the urgency of better understanding how prevention and treatment strategies may or may not help reduce costs.


Many policy analysts fear that eliminating the individual health insurance mandate and penalty from the Affordable Care Act of 2010 would lead to a "premium spiral," in which healthy people would drop coverage, premiums would soar, and the number of people with coverage would plummet. However, there are other provisions of the law that would greatly mitigate this effect. For example, the subsidies provided in the law to help people purchase coverage through health insurance exchanges would restrain a premium spiral by absorbing much of the impact of premium increases. We estimate that if the mandate were lifted, premiums in the individual market would increase by 12.6 percent-somewhat less than other estimates-with 7.8 million people losing coverage, versus other estimates for coverage loss of 16-24 million people. In sum, the Affordable Care Act would still cover 23 million people who would have been uninsured without the law. Our study suggests that although the mandate would have important effects on premiums and coverage, it might not be essential to the act's successful implementation. © 2011 Project HOPE-The People-to-People Health Foundation, Inc.


Villarivera C.,Lewin Group | Jain A.,Lewin Group | Zhang Y.,Medimmune | Goodman C.,Lewin Group
Health Affairs | Year: 2012

Diabetes, especially type 2 diabetes, is on the rise throughout the United States. Several national health organizations and professional medical societies advocate screening people in high-risk groups for diabetes. However, the US Preventive Services Task Force recommends screening only adults with hypertension. We examined evidence supporting screening high-risk adults, including studies using intermediate outcomes and modeling studies. We found a broad range of evidence of practical relevance to diabetes screening that merits consideration in developing new screening guidelines. This evidence could inform recommendations to expand coverage to screening of other high-risk groups and could facilitate the prevention and early treatment of diabetes. We recommend that the US Preventive Services Task Force consider these expanded sources of evidence and revise its recommendations accordingly. © 2012 Project HOPE-The People-to-People Health Foundation, Inc.


News Article | February 24, 2017
Site: www.npr.org

Indiana's Claims About Its Medicaid Experiment Don't All Check Out Indiana expanded Medicaid under the Affordable Care Act in 2015, with a few extra conditions that were designed to appeal to the conservative leadership in the state. The Federal government approved the experiment, called the Healthy Indiana Plan, or HIP 2.0, and it is now is up for another three-year renewal. But a close reading of the state's renewal application shows misleading and inaccurate information is being used to justify extending HIP 2.0. This is important because the initial application and expansion happened on the watch of then-Governor, now-Vice President Mike Pence. And Seema Verma, who is now President Trump's pick to lead the Centers for Medicare and Medicaid Services, helped design it. (Among other functions, CMS oversees all Medicaid programs.) So states are watching to see if the approval of Indiana's application is a bellwether for Medicaid's future. To get the program extended again, the Indiana Family and Social Services Administration has to prove to CMS that the experiment is working and that low-income people in the state are indeed getting access to care and using health care efficiently. The key part of Indiana's experiment requires low-income participants to make monthly payments. Advocates say this promotes recipients' taking personal responsibility for their health care. But some health policy experts say the information provided by the state shows that the provision isn't working as well as it should. Here are some examples: The Claim: Most Members Are Making Regular Payments To Maintain Coverage The Fact: A Lot Of People Are Missing The First Payment The state's application says that "over 92 percent of members continue to contribute [to their POWER accounts] throughout their enrollment." This claim is missing a lot of context. To understand why it's important, here's a primer on how HIP 2.0 works: Members can get HIP 2.0's more complete coverage, the HIP Plus plan, by making monthly payments into a "Personal Wellness and Responsibility Account," or POWER account. If they don't make the payments, there are penalties. If a recipient makes less than the federal poverty level — about $12,000 a year — they're bumped to HIP Basic, a lower-value plan that requires copays and doesn't include vision or dental insurance. If a recipient is above the poverty line and misses a payment, they're locked out of coverage completely for six months. The state's claim that 92 percent of members make consistent payments is based on data in a report by the Lewin Group, a health policy research firm in Virginia that evaluated HIP 2.0's first year. But the Lewin report also says that when people are signing up for HIP 2.0, they can be declared "conditionally enrolled," which means they're eligible but have not yet made their first payment. According to the Lewin report, in HIP 2.0's first year, about a third of people who were conditionally enrolled never fully joined. "I don't see those numbers being captured," says Dr. David Machledt, senior policy analyst with the National Health Law Program, which advocates for low-income individuals. Machledt says the state should recalculate the figure to include those people, because it's potentially an indicator that people are confused about how the program works, or that they can't afford the payments. He adds that the figure cited is also based on the first year of HIP 2.0, and that the rate of losing coverage for missing payments has increased substantially since then. The Fact: More Than Half of People Don't Even Know They Have One The state says the POWER account is promoting personal responsibility in health care; meaning, if someone is aware of how much they are spending, they'll choose their medical care wisely. As evidence, the state writes in its application that 40 percent of HIP Plus members "check their [POWER Account] balance at least once a month." Again, the state leaves out important context. According to the Lewin report, most people in HIP Plus didn't know they had a POWER account. Of those who did, 40 percent of them checked their account once a month, but that's much smaller than 40 percent of all HIP Plus members. In fact, an analysis of the numbers shows only about 19 percent of HIP Plus members reported checking the balance of their POWER account monthly. Rather than evidence of personal responsibility, Judy Solomon, Vice President for Health Policy at Center on Budget and Policy Priorities, sees evidence of confusion. "I think that's another really significant finding [in the Lewin report] that so far I have never seen the state come to terms with," says Solomon. A spokesperson for the state wrote in an e-mail that the phrase, "of the members surveyed" was unintentionally omitted from the application. The message did not address the overall concern that the statement was misleading. The Claim: People On HIP Plus Are More Responsible The Fact: Experts Say HIP Plus Is Just Better Insurance The application also says "HIP members who contribute [to their POWER accounts] are twice as likely to obtain primary care (31 percent to 16 percent), have better prescription drug adherence (84 percent to 67 percent), and rely less on the emergency room for routine treatment." Machledt says simply showing that HIP Plus members use the emergency room less frequently than HIP Basic members doesn't tell the whole story. "They don't talk about the risk profile of those different groups," Machledt says. He says people who are above the poverty line are generally less likely to frequent the ER in the first place. "There's no evidence to me that they've risk adjusted... to show that they're comparing apples to apples," he says. Indiana argues that the higher levels of primary care use and drug adherence for those making POWER account payments, "confirms the principle of personal responsibility." But Solomon says the differences in behaviors actually just confirm something else: Those who pay their POWER account have better insurance. HIP Plus makes it easier for people to access primary care and to adhere to their prescription drug regimens, Solomon says. "The policy for people in HIP Plus is that they get a three-month supply of drugs, and can even use mail order, without any copays," she says. Meanwhile, people in HIP Basic have to pay copays and are limited to a one-month supply of drugs. Solomon says getting less primary care and relying on the ER for health crises is worse for patients and could also mean higher costs. "You have large numbers of people that are not getting care in the right place at the right time, and not maintaining adherence to prescription drug regimens." The Claim: HIP 2.0 Is Meeting Its Enrollment Projections The Fact: No, It Isn't The state's application reads "HIP has continued to meet its enrollment goals with over 394,000 individuals fully enrolled in HIP as of December 1, 2016." But the state isn't meeting its enrollment goals. According to a chart published in 2014 in Indiana's original proposal for HIP 2.0, its enrollment goal for December of 2016 was higher — 424,339. (The chart to the right is off by a month, because the state started HIP 2.0 a month later than planned, so the actual projection for December 2016 appears on the line for November 2016.) The most recent enrollment report shows 403,142 HIP members in January 2017, short of the state's projection of 427,702. The Fact: The Survey Data Is Not Reliable There's reason to doubt the survey results that underlie much of the Lewin report, according to Dr. Leighton Ku, director of the Center for Health Policy Research at the Milken Institute School of Public Health at George Washington University. "They were not using what would generally be considered best practices in their survey methodology," Ku says. Ku says the methodology available to the public is vague. From the information provided, he says there are multiple ways that bias could have been introduced into the survey results used in the Lewin report. For one thing, the sample sizes of the survey were too small to draw accurate conclusions, Ku says, and the data was analyzed using "not an optimal method." Ku says the results are not displayed in a scientific manner, and that it appears the survey and analysis were done in a hurry. "You would not, as a survey researcher, have great confidence in the results that they show," he says. As Indiana looks to extend HIP 2.0, health policy experts say it's important to get an accurate picture of how well the program is working. Requiring POWER account payments was key to making the program a reality in Indiana, but they say a more traditional Medicaid expansion — one that does not require monthly payments and 6-month lockouts — is a better option. Dr. Jennifer Walthall heads the Indiana Family and Social Services Administration, the government agency that runs HIP 2.0. She said that in order to comment on discrepancies between the state's extension application and the Lewin report, "I would have to go back and look at the way that these data were reported." She continued, "I'm happy to look into that and get that for you." In a separate prepared statement, the agency noted that the state "has made significant achievements" on HIP 2.0's stated goals and that it looks forward "to continuing to build on these successes with future versions of HIP ... The analysis of this program is constant and ongoing and includes continuous conversation with our federal partners to discuss all aspects of the proposed waiver as well as program outcomes." If the application does not go forward, the state could choose to expand Medicaid under the Affordable Care Act without any special provisions, or not accept the expansion at all. The federal government is welcoming public comment on Indiana's application until March 17. This story is part of a reporting partnership with NPR, WFYI, Side Effects Public Media and Kaiser Health News.

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